Post-kala-azar dermal leishmaniasis and leprosy: case report and literature review

Abstract

BackgroundPost-kala-azar dermal leishmaniasis (PKDL) is a dermal complication of visceral leishmaniasis (VL), which may occur after or during treatment. It has been frequently reported from India and the Sudan, but its occurrence in South America has been rarely reported. It may mimic leprosy and its differentiation may be difficult, since both diseases may show hypo-pigmented macular lesions as clinical presentation and neural involvement in histopathological investigations. The co-infection of leprosy and VL has been reported in countries where both diseases are endemic. The authors report a co-infection case of leprosy and VL, which evolved into PKDL and discuss the clinical and the pathological aspects in the patient and review the literature on this disease.Case presentationWe report an unusual case of a 53-year-old female patient from Alagoas, Brazil. She presented with leprosy and a necrotizing erythema nodosum, a type II leprosy reaction, about 3 month after finishing the treatment (MDT-MB) for leprosy. She was hospitalized and VL was diagnosed at that time and she was successfully treated with liposomal amphotericin B. After 6 months, she developed a few hypo-pigmented papules on her forehead. A granulomatous inflammatory infiltrate throughout the dermis was observed at histopathological examination of the skin biopsy. It consisted of epithelioid histiocytes, lymphocytes and plasma cells with the presence of amastigotes of Leishmania in macrophages (Leishman’s bodies). The diagnosis of post-kala-azar dermal leishmaniasis was established because at this time there was no hepatosplenomegaly and the bone marrow did not show Leishmania parasites thus excluding VL. About 2 years after the treatment of PKDL with liposomal amphotericin B the patient is still without PKDL lesions.ConclusionPost-kala-azar dermal leishmaniasis is a rare dermal complication of VL that mimics leprosy and should be considered particularly in countries where both diseases are endemic. A co-infection must be seriously considered, especially in patients who are non-responsive to treatment or develop persistent leprosy reactions as those encountered in the patient reported here.

Post kala-azar dermal leishmaniasis: A threat to elimination program

“…They showed that nodular PKDL was more likely (86%) and macular PKDL less likely (35%), resulted in infected sandflies as compared with VL (67%), and concluded that PKDL is nearly equally infectious as that of VL. This conclusion was consistent with the fact that PKDL patients go untreated for years due to scarcity of adequate diagnostic tools and resemblance with leprosy [2], accounting for their higher cumulative transmission potential than that of VL patients. Although the VL elimination program is on the verge of its accomplishment (1 case per 10000 persons per year), PKDL stands as a major obstacle as the contribution of PKDL cases nearly triples after intensive WHO interventions highlighting the need for prompt PKDL control program [152,153].…”

“…Based on its clinical manifestations, this disease occurs into self-healing cutaneous leishmaniasis (CL), skin mucosal ulcers forming mucocutaneous leishmaniasis (MCL), and fatal visceral leishmaniasis (VL), which may be followed by a dermal sequel called PKDL. PKDL, which can be confused with leprosy [ 2 ], develops after six months and sometimes up to 5 years following the previous VL incidence, and 15% of PKDL cases have shown no prior kala-azar infection [ 3 ]. But a hospital-based retrospective study on Indian PKDL subjects showed that 20% of cases had no antecedent of VL [ 4 ].…”

Visceral Leishmaniasis: Evaluation of Diagnostic Tools, Therapeutic Regimens, and Associated Risk Factors in Areas with Frequent Outbreaks in South Sudan and Sudan: Case Reports and Review of Literature

“…Fever, weight loss, fatigue, and anemia are primary stages, accompanied with enlargement of spleen the most common feature then swelling of liver but not as severe as in spleen and lymph nodes; this is the characteristic of African Kala-azar. Meanwhile, Chinese type is well known for causing inflammation of nodes [51]. PKDL skin damage commonly seen on the face, hands, feet and abdomen.…”

“…PKDL skin damage commonly seen on the face, hands, feet and abdomen. Familiar features of "Black Sickness" such as in South Sudan and Sudan as in Figure 6 above [51].…”

Algoritmo para o diagnóstico molecular da leishmaniose visceral

“…21,72 Sob o ponto de vista clínico e epidemiológico, ressalta-se também a importância da definição do agente causador de tal moléstia, diante do encontro de outros tripanossomatídeos que não leishmânias, no vetor das leishmanioses, os flebotomíneos, 83 bem como de haver na literatura descrição de manifestações cutâneas relacionadas com a lesão dérmica pós-calazar (PKDL) envolvendo L. (L.) infantum. 26 Portanto, casos de leishmaniose tegumentar (LT) causada por essa espécie fora do Velho Mundo, inclusive no Brasil, 11,82 já foram descritos, como também, caso de LV causada por espécie dermotrópica. 5 Assim como manifestações incomuns de leishmaniose causada por L. (L.) infantum, também foram descritos casos de coinfecção de espécies causadoras de LT e LV.…”